"...older population getting older."

"Thirty-three million older Americans enrolled in Medicare."

"...hospitalization leads to a downward spiral..."

"...certain illnesses are confined primarily to the elderly."

"...elderly become less mobile..."

"...elderly unprepared to accept new status..."

Chapter Quick Links:

  Aging Americans
  Uniqueness of Geriatric Healthcare Needs
  Overall Needs of the Elderly
 

I. The Multiplicity of Needs of the Elderly

Aging Americans

As parents of the Baby Boomers age in tandem with the aging of the baby boomers themselves, the healthcare needs of the elderly will continue to expand exponentially. As of 1998, approximately 34 million persons, representing about 13 percent of the U.S. population, were age 65 or older. This number has increased by 9 percent since 1990 and by 2030, the number of persons 65 and older is expected to have tripled to 93 million.   The older population is also getting older. Since 1990, the size of each age group has increased progressively, as follows: the 65-74 age group, eight times; the 75-84 age group, 16 times and the 85+ age group, 31 times.  In 1997, people reaching 65 had a life expectancy of 17.6 years.  The 65 and older population is projected to represent 13 percent of the population in 2000 and 20 percent of the population by 2030. ["Profiles of Older Americans: 1998," Administration on Aging]

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These trends will significantly increase healthcare delivery costs, which now represent 13 percent of the gross national product.  By 2030, one in five Americans will be eligible for Medicare.   [Foundation for Health in Aging, American Geriatric Society].  In 1995, almost 30 percent of older Americans assessed their own health as "fair" or "poor," compared to less than 10 percent in the general population. More than one third reported being limited by at least one chronic condition. In 1995, this older population represented 40 percent of all hospital stays and 49 percent of all days of care in hospitals.  The average length of stay for this older group was 7.1 days, compared to 5.4 days for those patients under 65. Thirty-three million older Americans are enrolled in Medicare, with slightly more than four out of five actually receiving medical services covered by Medicare. Eleven million elderly persons received services under Medicaid.["Profiles of Older Americans: 1998,"  Administration on Aging].

As America ages, the healthcare community needs to make healthcare more responsive to the ever increasing needs of the aging population, even as it attempts to contain costs within the Medicare/health insurance systems.  In 1990, older Americans averaged nine contacts with physicians, while those under 65 averaged only five contacts [The Merck Manual of Geriatrics, 2nd Edition].  Decision making for the care of older Americans is complicated by multiple chronic conditions, resulting in possible drug interactions. All too often this geriatric healthcare is fragmented, frequently to the detriment of the patient.

Typically, the healthcare management of elderly patients is complicated by the higher incidence of atypical nonspecific symptoms in common diseases, the high rate of multiple medications, and difficulty in predicting response to treatment.  Often hospitalization for one condition leads to a downward spiral because of reduced functional status and inadequate outpatient care.

Uniqueness of Geriatric Healthcare Needs

Because of structural and physiological changes of normal aging, the healthcare needs of the elderly are unique and differ significantly from those of the general adult population, much the same as the healthcare needs of children and adolescents differ from the adult population. 

Geriatrics is a specialized area of healthcare in much the same way as pediatrics is specialized, often for similar reasons. For example, in general, the effect of medications on children is much greater than on adults.  Likewise, the effect of medications on the elderly may be much greater or at least different from the effect on the general adult population.  Just as certain illnesses or conditions are confined to or are more common in children, certain illnesses are confined primarily to the elderly or are at least more common in the elderly. Just as pediatricians coordinate the healthcare of children, geriatricians need to be coordinating the healthcare of the elderly.  The elderly need a problem-oriented approach that includes a full continuum of care [The Merck Manual of Geriatrics, 2nd Edition].

Overall Needs of the Elderly

The breadth of needs of the elderly encompasses a wide continuum, which includes functional, environmental, psychological, social, educational and financial issues, as well as physiological and structural issues.  As a group, because of structural, physiological and psychological changes, as well as financial constraints, the elderly often have more difficulty accessing adequate and appropriate healthcare [Innovations in Eldercare, The Advisory Board Company, 1997].  The elderly challenge the healthcare system because of the multiple levels of their needs.

Functional changes often occur as part of the natural aging process.   Most commonly, these manifest themselves in the form of increased frailty as the result of  poor nutrition, fluid abnormalities, heat regulation disorders, gait disturbances, falls, immobility, confusion, syncope, sleep abnormalities, incontinence, and/or pressure sores [The Merck Manual of Geriatrics, 2nd Edition].  As a result, the elderly become increasingly less mobile, so that even a trip to the local pharmacy may become an ordeal.

As a consequence of this decreased functional status of aging, changes in living arrangements often need to be made. The continuum of these modified living arrangements includes home health care, senior communities, assisted living facilities, rehabilitation facilities, skilled nursing facilities, and hospice facilities for the terminally ill. The elderly greatly need professional assistance in assessing their functional and financial status to determine the most appropriate, least restrictive level of alternative living environment.

Psychological changes in the elderly may manifest themselves as decreased attentiveness, impaired memory, confusion, depression, anxiety with regard to health status, and reduced self esteem because of the presence of any of the preceding. Since the elderly may be loathe to acknowledge or recognize these as problems, their presence often go unheeded by healthcare providers who tend to be more focused on the physical aspects of their patients' status.

Major sociological changes also may result from retirement, death or illness of a spouse, friends and family; functional disability; impaired cognition; pain and suffering; modified living arrangements; neglect and elder abuse; diminished life expectancy; and so forth.  These changes impact greatly on the social status of the elderly who may then withdraw further from society.  Lack of support and socialization is associated with increased risk of mortality [The Merck Manual of Geriatrics, 2nd Edition].  These sociological changes, as well as issues such as long-term care insurance; health insurance coverage, including Medicare and Medicaid; advanced directives; and funeral arrangements need to be addressed by professionals as part of fully integrated geriatric services.

As the preceding changes evolve, the elderly may be unprepared to acknowledge, much less accept their new status in life.  As they tend to withdraw, the elderly may not make the effort to keep themselves informed as to how best to access healthcare services. Since they often live in fear of serious, life-threatening illnesses, they may tend to abide by the concept that "what you don't know won't hurt you."  The elderly and/or their families need to be fully informed of these healthcare needs and how best to address them to provide the highest functional level for the longest period of time.

Continue to Chapter 2, " Unmet Healthcare Needs"

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